What is a Pap smear? is a medical procedure in which a sample of cells from a woman's cervix is collected and spread (smeared) on a microscope slide. The cells are examined under a microscope in order to look for pre-malignant or malignant changes.

A Pap smear is a simple, quick, and relatively painless screening test.

Who should have a Pap smear? Start the test at : 3 years after initiation of sexual intercourse OR the age of 21 If did not have intercourse ??? Why Then an annual screening

Who should have a Pap smear? After age of 30 : If had 3 consecutive normal smear AND no high risk factors (DES exposure, HIV infection, or other immunodeficiencies) screen every 2-3 years

Who should have a Pap smear? HPV test : Indicated at age 30 if  –ve the screening can be delayed for 3 years Another option : Every 3 years do pap smear + HPV DNA test At the age 0f 70 screening could be stoped if 3 con. tests were normal & no risk factors

Who should have a Pap smear? Women who have had a hysterectomy in which the cervix is not removed, called subtotal hysterectomy, should continue screening following the same guidelines as women who have not had a hysterectomy. Pregnancy does not prevent a woman from having a Pap smear. Pap smears can be safely done during pregnancy. Pap smear testing is not indicated for women who have had a hysterectomy (with removal of the cervix) for benign conditions.

The screening guidelines of several key medical organizations are summarized in the table below :

Which women are at increased risk for having an abnormal Pap smear? HPV: The principal risk factor is infection with the genital wart virus, also called the human papillomavirus (HPV) About 95%-100% of cervical cancers are related to HPV infection.

Which women are at increased risk for having an abnormal Pap smear? Smoking: common risk factor for premalignant and malignant changes in the cervix is smoking. Smoking increased the risk of cervical cancer about two to four fold.

Which women are at increased risk for having an abnormal Pap smear? Weakened immune system: Women whose immune systems are weakened or have become weakened by medications (for example, those taken after an organ transplant) also have a higher risk of precancerous changes in the cervix.

Which women are at increased risk for having an abnormal Pap smear? Medications: Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at increased risk. Other risk factors: for precancerous changes in the cervix and an abnormal Pap testing include having multiple sexual partners and becoming sexually active at a young age.

Risks of having PAP smear Generally no risks even in pregnant lady. there is a very remote chance of infection from a Pap smear .

1- Should be not menstruating. How is a PAP smear done? Prerequisites : 1- Should be not menstruating. 2- Avoid using vaginal douche, spermicidal gel or medications. 3- Avoid sexual intercourse prior to the test. Explain to the patient what are you doing. The result will be available within two to three weeks. Position her buttocks just at the edge or just over the edge of the exam table.

PAP smear kit

How is a PAP smear done? Inspect the Vulva look for: -Discolorations of the skin -Skin lesions -Masses -Discharge -Signs of trauma -Pubic hair distribution (triangular = normal) Warm the speculum by hot water, Insert it in the vagina. Open the speculum and usually the cervix is immediately visible.

How is a PAP smear done? - Using a spatula>> Ectocervical sample - Cervical brush>>Endocervical sample Types of PAP smear: - Traditional PAP smear. - Liquid cytology.

How is a PAP smear done?

How to read and analyze pap smear Pap smear analysis and reports are all based on a medical terminology system called The Bethesda System The system was developed (at the National Institutes of Health (NIH) in 2001

How to read and analyze pap smear There are two types of epithelial cells in the cervix : A- Squamous Abnormalities (cells that cover most of the external part of the cervix) (ASC-US) Atypical Squamous Cells: Unknown Significance .  (LSIL) Low Grade Squamous Intraepithelial Lesion   (HSIL); High Grade Squamous Intraepithelial Lesion   Squamous Cell Carcinoma  

How to read and analyze pap smear B- Glandular Abnormalities (cover the lining of the uterus opening and canal) Atypical cells, not otherwise specified Atypical cells, favor neoplastic Adenocarcinoma in situ Adenocarcinoma (can be endometrial (uterus), endocervical (cervix), extrauterine (origin from outside uterus and cervix), or the site of the malignancy cannot be determined based on the Pap smear ) .

How to read and analyze pap smear Glandular abnormalities are much less common than squamous abnormalities. A diagnosis like adenocarcinoma in situ is one of the rarest diagnosis made on a Pap smear frequently requires consultation among pathologists.

Bethesda system used to: What information is included on a Pap smear report? Bethesda system used to: To reduces the possibility that different laboratories might report different results for the same smear . To make Pap smear reports less confusing for the clinicians who request the tests and for their patients.

Past Pap Smear Classification Systems (Some pathologists may still use terms from these systems)

Bethesda system

Smear report should include all the following : The Pap The name of the woman. The name of the pathologist and/or the cytotechnologist who read the smear. The source of the specimen. The date of the least menstrual period of the woman. Menstrual status of the woman. Relevant medical history of the woman. The number of slides . The specimen adequacy. The final diagnosis.

How is the final Pap smear diagnosis made? The final Pap smear diagnosis is based on three determining factors: The patient's history Sample adequacy The presence or absence of cellular abnormalities.

How is the final Pap smear diagnosis made? The final diagnosis is a short statement that summarizes what the reader has found.

Example of the final Pap smear diagnosis Within normal limits Absence of endocervical cells on the Pap smear Unreliable Pap smear due to inflammation Atypical squamous cells of undetermined significance (ASCUS) Low-grade squamous intraepithelial lesion (LSIL) High-grade squamous intraepithelial lesion (HSIL)

What are the possible recommendations for follow-up after a Pap smear?

What are the possible recommendations for follow-up after a Pap smear?

What are the possible recommendations for follow-up after a Pap smear?

What are the possible recommendations for follow-up after a Pap smear?

What are the possible recommendations for follow-up after a Pap smear?

What are the possible recommendations for follow-up after a Pap smear?

What are the possible recommendations for follow-up after a Pap smear?

What treatments are available if a Pap smear is abnormal? If a Pap smear is interpreted as abnormal, there are a number of different management and treatment options including : colposcopy . Conization . cryocauterization . laser therapy . large-loop excision of the transformation zone.

What treatments are available if a Pap smear is abnormal? Colposcopy : is a procedure that allows the physician to take a closer look at the cervix. The colposcopey is essentially a magnifying glass for the cervix. For colposcopy to be adequate, the whole cervical lesion, as well as the whole transformation zone (the transition between the vagina-like lining and the uterus-like lining), must be seen.

Colposcopy During colposcopy, the cervix is cleaned and soaked with 3% acetic acid. This acid not only cleans the surface of the cervix but it also allows cellular abnormalities to show up as white areas (called acetowhite epithelium or acetowhite lesions).

Colposcopy

Colposcopy If suspicious areas of cervical tissue are seen during colposcopy, a biopsy (tissue sampling) is often done. The sample is sent to the laboratory for analysis by a pathologist and the biopsy results determine the next step in the treatment. The procedure is essentially painless and quite simple, usually taking only several minutes to perform. Generally, the woman is instructed not to have intercourse, douche, or use tampons for about a week afterwards if a biopsy is done.

Colposcopy

Colposcopy Pregnancy is not a contraindication to colposcopy. Colposcopy can adequately evaluate 90% of women who have abnormal Pap smear results.

Colposcopy

Conization Conization : allows the entire area of abnormal tissue to be removed and provides the maximum amount of cervical tissue for laboratory evaluation to rule out the presence of invasive cancer. After the cervical area is visualized, generally by colposcopy, a cone-shaped specimen of tissue (perhaps 1/2-1 inch long and 3/4 inch wide) is taken from around the endocervical canal.

Conization

Conization For three weeks after the procedure, the woman needs to avoid douching and using tampons and refrain from sexual intercourse. Cure rates close to 100% are achieved with conization as long as the cells along the margins of treatment are normal. Conization is usually done on an out-patient basis under anesthesia in a hospital or surgical facility.

Conization Hysterectomy (surgical removal of the uterus and the cervix) for non-cancerous abnormal Pap smears is now rarely done. A hysterectomy is appropriate only for those women who are finished with childbearing and have severe pre-cancerous abnormalities that have persisted despite other treatments. It may also be appropriate for women with certain specific findings after conization. Conization is generally performed only on women who have had unsatisfactory colposcopy results, have adenocarcinoma in situ (a diagnosis of cancer) already, or whose Pap smears suggest they may have some invasion of cancer into the nearby tissue. With conization, there are associated risks from anesthesia and postoperative hemorrhage (bleeding-in about 10% of cases) as well as possible future adverse effects on fertility.

Conization

Cryocauterization Cryocauterization: is a simple and safe procedure. A probe, called a cryoprobe, is first cooled by carbon dioxide and then touched to the abnormal cervical area. This freezes and kills the cells, resulting in the sloughing of the abnormal tissue. A woman undergoing cryocauterization can expect a watery vaginal discharge for several weeks after the procedure.

Cryocauterization

Cryocauterization

Laser Therapy Laser therapy: Laser therapy makes use of the principle that laser light can be produced by electricity running through gas. In the treatment of cervical lesions, the gas is usually carbon dioxide. This type of laser can instantly boil water and therefore can also be used to kill and vaporize cells. When a laser beam (using a tiny wand called a micromanipulator) is directed into the cervix at an area of abnormal cervical tissue, the light energy is converted to heat, which in turn causes cell death, as occurs with cryocauterization.

Laser Therapy However, the laser apparatus is expensive, and its use requires more skill than other treatment options, such as cryocauterization. The procedure is also painful and generally requires general anesthesia. The benefit of laser therapy is that it may cause less cervical scarring as compared to cryocauterization. This in turn may mean that, should the woman need colposcopy in the future, the chances of adequately viewing her cervix may be better after laser therapy.

Laser Therapy

LEEP Large-loop excision (LEEP) of the transformation zone : removes the cervical transformation zone (the area where the vaginal-type lining changes to the uterine-type lining) using a thin-wire loop to administer electrocautery. It allows samples to be collected for additional tissue analysis and can be performed in the office under local anesthesia.

LEEP Specialized (more frequent) follow-up is necessary after LEEP. This follow-up includes Pap smears, colposcopy, and sometimes other techniques. When there is no more evidence of abnormal cervical tissue, it may be possible to resume annual screening Pap smears.

LEEP

What is the follow-up after treatment for an abnormal Pap smear? Women who have undergone any one of the above-described treatment procedures require special follow-up schedules. They must be evaluated and checked until the physician is fully convinced that routine Pap smears can be resumed. Follow-up is crucial after treatment for an abnormal Pap test.

What is the current status of human papilloma virus (HPV) typing? HPV IS SEXALLY TRANSMITTED VIRUS. MANY SEXALLY ACTIVE PEOPLE ARE CARRIERS OF HPV. Types (16,18) are more likely to be associated with cervical cancer. Combined test : primary screening test for cervical cancer ,consists of HPV testing +pap screening.

HPV

When should women start and stop having Pap smears, and how often should Pap smears be performed? -Pap smears should be started within 3 years of first sexual activity or age 21, which ever comes first. - Older women who have had many normal Pap smears in a row and have been regularly screened are highly unlikely to have an abnormal Pap smear.

- women who have had a subtotal hysterectomy should be screened . When should women start and stop having Pap smears, and how often should Pap smears be performed?  - Women who have had a total hysterectomy do not derive any benefit from screening for cervical cancer.  - women who have had a subtotal hysterectomy should be screened .

When should women start and stop having Pap smears, and how often should Pap smears be performed? - Women who have had a hysterectomy for abnormal Pap smears have their own special recommendations. - women who have had cervical cancer, exposure to diethylstilbestrol, or a compromised immune system should continue annual screening .

When should women start and stop having Pap smears, and how often should Pap smears be performed? - Women who have had a hysterectomy for CIN2 or CIN3 should be screened until they have had three normal Pap smears. if no abnormal Paps show up in 10 years, they can stop having Pap tests .

What is the current status of the newer Pap smear technologies? liquid-based cytology : cervical cells are obtained as usual but a new technique is used to prepare the slides for analysis. The physician puts the cell sample into a vial of liquid preservative. The cells are then sent to the laboratory where they are filtered and spread on glass slides. This method removes any contamination from blood or mucous.

What is the current status of the newer Pap smear technologies? Computer systems are now being developed to assist by providing an automated analysis of slides. Slides containing abnormally appearing cervical cells can first be automatically identified and then subjected to a second, manual re-screening.